Is the antimicrobial (anti-microbial) treatment used on slings toxic?

Antimicrobial Treatment on Slings: Safety and Toxicity Concerns

Based on the available evidence, the antimicrobial treatments used on slings are generally not toxic and appear to be safe for most patients, with the benefits outweighing potential risks when used appropriately.

Understanding Antimicrobial Treatments on Slings

Midurethral synthetic slings are commonly used in the treatment of stress urinary incontinence (SUI) in women, with success rates over 80% 1. These slings may be treated with antimicrobial agents to prevent infection, but concerns exist about potential toxicity.

Evidence on Safety and Efficacy

• A study specifically examining infection rates after midurethral synthetic sling surgery found no significant difference in urinary tract infection (UTI) rates between patients who received only preoperative antibiotics (9.5%) versus those who received both pre- and postoperative antibiotics (6.8%) 2
• Importantly, adverse events related to antibiotic use were significantly higher in patients receiving postoperative antibiotics (7.8% vs 0.9%, p=0.03) 2
• These adverse events included:
  • Yeast infections (63% of adverse events)
  • Rash (12.5%)
  • Nausea (12.5%)
  • Colitis (12.5%)

Antimicrobial Resistance Considerations

When evaluating antimicrobial treatments on medical devices like slings, several important factors must be considered:

• Antimicrobial agents can disturb the ecological balance of normal microflora, which acts as a barrier against colonization of potentially pathogenic microorganisms 3
• Overuse and misuse of antimicrobials contribute to antimicrobial resistance (AMR), which is a major global public health concern 4
• The clinical guidelines for vulvar and vaginal surgery recommend judicious use of antimicrobial prophylaxis, with intravenous antibiotics administered routinely within 60 minutes before vaginal hysterectomy, but less clear recommendations for vaginal surgery without hysterectomy 5

Clinical Implications and Recommendations

Based on the evidence, the following approach is recommended:

1. For standard midurethral sling procedures:

   • Single-dose preoperative antibiotic prophylaxis appears sufficient for most patients 2
   • Postoperative antibiotics are generally unnecessary and may increase adverse events 2

2. For high-risk patients or complex cases:

   • Consider individual risk factors for infection
   • Follow institutional protocols for antimicrobial prophylaxis
   • Monitor for signs of infection postoperatively

Potential Concerns and Pitfalls

While antimicrobial treatments on slings generally appear safe, clinicians should be aware of:

• Potential for allergic reactions to antimicrobial agents
• Risk of selecting for resistant organisms with unnecessary antimicrobial use
• Disturbance of normal vaginal flora, which could lead to secondary infections such as candidiasis 3

Conclusion

The evidence suggests that antimicrobial treatments used on slings are not significantly toxic when used appropriately. The primary concern is not direct toxicity but rather the potential for adverse events related to antimicrobial use and the broader issue of antimicrobial resistance. A single-dose preoperative antibiotic appears to be the optimal approach for most patients undergoing midurethral sling procedures, balancing infection prevention with minimizing adverse effects.